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Progress Notes are the part of a medical record where healthcare professionals record details to document a patient 's clinical status or achievements during the course of a hospitalization or over the course of outpatient care. [1] Reassessment data may be recorded in the Progress Notes, Master Treatment Plan (MTP) and/or MTP review.
The HL7 Consolidated Clinical Document Architecture ( C-CDA) is an XML -based markup standard which provides a library of CDA formatted documents. Clinical documents using the C-CDA standards are exchanged billions of times annually in the United States. [1] [2] [3] All certified Electronic health records in the United States are required to ...
SOAP note. The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by healthcare providers to write out notes in a patient 's chart, along with other common formats, such as the admission note. [1] [2] Documenting patient encounters in the medical record is an integral part of practice ...
In the United States Department of Defense, the Integrated Master Plan ( IMP) and the Integrated Master Schedule (IMS) are important program management tools that provide significant assistance in the planning and scheduling of work efforts in large and complex materiel acquisitions. [1] The IMP is an event-driven plan that documents the ...
These documents must be capable of including data elements known as the "Common MU Data Set" that include: Patient name, sex, date of birth, race, ethnicity, preferred language, smoking status, problems, medications, medication allergies, laboratory tests, laboratory values/results, vital signs, care plan fields including goals and instructions ...
A Gantt chart is a type of bar chart [4] [5] that illustrates a project schedule. [6] This chart lists the tasks to be performed on the vertical axis, and time intervals on the horizontal axis. [4] [7] The width of the horizontal bars in the graph shows the duration of each activity. [7] [8] Gantt charts illustrate the start and finish dates of ...
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